Residency Support During a Natural Disaster: Hurricane Ida

Description Natural disasters can have extraordinary impacts on a community and its infrastructure. Disasters can weaken systems that provide crucial resources, such as shelter, food security, water and health care. Recently, southeast Louisiana sustained devastating damage from Hurricane Ida on the 16th anniversary of Hurricane Katrina. Our medical workforce faced challenges caring for patients in a facility without potable water and powered by a generator. With the support of corporate entities and our academic institution, however, these barriers were quickly overcome and thus highlights the importance of collective resilience in the face of a natural disaster.

Recurrent spontaneous globe subluxation: a case report and review of manual reduction techniques

BACKGROUND

Spontaneous globe subluxation is an uncommon problem that develops acutely and can present with significant patient distress from ocular pain and vision loss.

OBJECTIVES

To present an unusual case of recurrent spontaneous globe subluxation and describe several methods emergency physicians can use to reduce a subluxation.

CASE REPORT

We describe a patient with recurrent spontaneous globe subluxation who presented to the Emergency Department with acute ocular pain and vision loss. The subluxation was emergently reduced, resolving the pain and restoring normal vision. Various manual reduction techniques are discussed.

CONCLUSION

There are a number of manual reduction techniques used for treating spontaneous globe subluxation.

In vivo and in vitro pharmacological studies of methoxycarbonyl-carboetomidate

BACKGROUND

We previously developed 2 etomidate analogs that retain etomidate's favorable hemodynamic properties but whose adrenocortical effects are reduced in duration or magnitude. Methoxycarbonyl (MOC)-etomidate is rapidly metabolized and ultrashort acting whereas (R)-ethyl 1-(1-phenylethyl)-1H-pyrrole-2-carboxylate (carboetomidate) does not potently inhibit 11β-hydroxylase. We hypothesized that MOC-etomidate's labile ester could be incorporated into carboetomidate to produce a new agent that possesses favorable properties individually found in each agent. We describe the synthesis and pharmacology of MOC-(R)-ethyl 1-(1-phenylethyl)-1H-pyrrole-2-carboxylate (MOC-carboetomidate), a "soft" analog of carboetomidate.

METHODS

MOC-carboetomidate's octanol:water partition coefficient was determined chromatographically and compared with those of etomidate, carboetomidate, and MOC-etomidate. MOC-carboetomidate's 50% effective concentration (EC(50)) and 50% effective dose for loss of righting reflexes (LORR) were measured in tadpoles and rats, respectively. Its effect on γ-aminobutyric acid A (GABA(A)) receptor function was assessed using 2-microelectrode voltage clamp electrophysiological techniques and its metabolic stability was determined in pooled rat blood using high performance liquid chromatography. Its duration of action and effects on arterial blood pressure and adrenocortical function were assessed in rats.

RESULTS

MOC-carboetomidate's octanol:water partition coefficient was 3300 ± 280, whereas those for etomidate, carboetomidate, and MOC-etomidate were 800 ± 180, 15,000 ± 3700, and 190 ± 25, respectively. MOC-carboetomidate's EC(50) for LORR in tadpoles was 9 ± 1 μM and its EC(50) for LORR in rats was 13 ± 5 mg/kg. At 13 μM, MOC-carboetomidate enhanced GABA(A) receptor currents by 400% ± 100%. Its metabolic half-life in pooled rat blood was 1.3 min. The slope of a plot of the duration of LORR in rats versus the logarithm of the hypnotic dose was significantly shallower for MOC-carboetomidate than for carboetomidate (4 ± 1 vs 15 ± 3, respectively; P = 0.0004123). At hypnotic doses, the effects of MOC-carboetomidate on arterial blood pressure and adrenocortical function were not significantly different from those of vehicle alone.

CONCLUSIONS

MOC-carboetomidate is a GABA(A) receptor modulator with potent hypnotic activity that is more rapidly metabolized and cleared from the brain than carboetomidate, maintains hemodynamic stability similar to carboetomidate, and does not suppress adrenocortical function.

Six Sigma process utilization in reducing door-to-balloon time at a single academic tertiary care center

BACKGROUND

Rapid reperfusion in patients with ST-elevation myocardial infarction (STEMI) is associated with lower mortality. Reduction in door-to-balloon (D2B) time for percutaneous coronary intervention requires multidisciplinary cooperation, process analysis, and quality improvement methodology.

METHODS

Six Sigma methodology was used to reduce D2B times in STEMI patients presenting to a tertiary care center. Specific steps in STEMI care were determined, time goals were established, and processes were changed to reduce each step's duration. Outcomes were tracked, and timely feedback was given to providers.

RESULTS

After process analysis and implementation of improvements, mean D2B times decreased from 128 to 90 minutes. Improvement has been sustained; as of June 2010, the mean D2B was 56 minutes, with 100% of patients meeting the 90-minute window for the year.

CONCLUSION

Six Sigma methodology and immediate provider feedback result in significant reductions in D2B times. The lessons learned may be extrapolated to other primary percutaneous coronary intervention centers.

Inhibition of human alpha4beta2 neuronal nicotinic acetylcholine receptors by volatile aromatic anesthetics depends on drug hydrophobicity

BACKGROUND

Volatile aromatic compounds such as benzene are general anesthetics that cause amnesia, hypnosis, and immobility in response to noxious stimuli when inhaled. Although these compounds are not used clinically, they are frequently found in commercial items such as solvents and household cleaning products and are abused as inhalant drugs. Volatile aromatic anesthetics are useful pharmacological tools for probing the relationship between chemical structure and drug activity at putative general anesthetic targets. Neuronal nicotinic acetylcholine (nACh) receptors are ligand-gated ion channels widely expressed in the brain, which are thought to play important roles in learning and memory. In this study, we tested the hypothesis that aromatic anesthetics reversibly inhibit alpha(4)beta(2) neuronal nACh receptor function and sought to determine the structural correlates of receptor inhibition.

METHODS

Electrophysiological techniques were used to quantify the effects of 8 volatile aromatic anesthetics on currents elicited by 1 mM ACh and mediated by human alpha(4)beta(2) nACh receptors expressed in Xenopus oocytes.

RESULTS

All of the volatile aromatic anesthetics used in this study reversibly inhibited alpha(4)beta(2) nACh receptors with IC(50) values ranging from 0.00091 atm for 1,2-difluorobenzene to 0.045 atm for hexafluorobenzene. With the exception of hexafluorobenzene, all of the compounds had IC(50) values less than minimum alveolar concentration. Inhibitory potency correlated poorly with the cation-pi binding energies of the compounds (r(2) = 0.48, P = 0.059). However, there was a good correlation between inhibitory potency and the octanol/gas partition coefficient (r(2) = 0.87, P = 0.0008).

CONCLUSIONS

Volatile aromatic anesthetics potently and reversibly inhibit human alpha(4)beta(2) neuronal nACh receptors. This inhibition may play a role in producing amnesia. In contrast to N-methyl-d-aspartate receptors, the inhibitory potencies of aromatic anesthetics for alpha(4)beta(2) neuronal nACh receptors seem to be dependent on drug hydrophobicity rather than electrostatic properties. This implies that the volatile aromatic anesthetic binding site in the alpha(4)beta(2) neuronal nACh receptor is hydrophobic in character and differs from the nature of the binding site in N-methyl-D-aspartate receptors.

Mucosal colonic tube fistula with antireflux wrap for antegrade colonic enema

Antegrade enemas can provide children with excellent faecal continence in situations where adequate control has been compromised because of underlying congential anomaly or poor surgical outcome in their treatment. The enema is often delivered through an appendicostomy. If the appendix is absent or utilized for another purpose, then placement of a chait tube or caecostomy button can provide access to the colon for the enema. However, these devices may be associated with breakages, accidental removal and leakage and replacement may require another operative procedure under a general anaesthetic. Full thickness colonic tubes can also be constructed at any point along the colon but in the author's experience, they can be associated with significant leakage of both gas and faecal material. The construction of a mucosal colonic tube with anti-reflux wrap is a technique that avoids the above problems and offers a distinctive advantage in selected situations. The technique relies on tabularising mucosa alone to create a continent fistula. Six children with severe soiling underwent the technique. The outcomes were evaluated using a modified quality of life score (QOLI). The score included assessment of soiling, staining, odour, self-esteem and socialization measure. Technical evaluation included analysis of the ease of catheterization and continence of the mucosal fistula site. All six patients had dramatic improvement in their faecal continence with complete resolution of soiling in all six. Follow up median is 42 months and the range is 6-48 months. QOLI scores improved from a total of 4.75 to 18.5. Possible range is 0-21. All the six fistula sites catheterize easily and no stenosis or faecal leakage has occurred. Two patients required treatment of minor granulations at the entry site of the fistula during the early healing phase.

Volatile aromatic anesthetics variably impact human gamma-aminobutyric acid type A receptor function

BACKGROUND

The gamma-aminobutyric acid type A (GABA(A)) and N-methyl-d-aspartate (NMDA) receptors are important inhibitory and excitatory neurotransmitter receptors, respectively, in the central nervous system. At the concentrations required to produce immobility in the face of a noxious stimulus, volatile aromatic anesthetics inhibit NMDA receptors to varying degrees, strongly suggesting that they also act at other targets to produce immobilization. In this study, we sought to assess the potential role that GABA(A) receptors play in mediating the behavioral actions of volatile aromatic anesthetics.

METHODS

Electrophysiological techniques were used to quantify the effects of eight volatile aromatic anesthetics and three clinical anesthetics on currents mediated by alpha1beta2gamma2L GABA(A) receptors expressed in Xenopus oocytes.

RESULTS

At equivalent minimal alveolar anesthetic concentration multiples, volatile aromatic anesthetics vary widely in the degrees to which they enhance GABA(A) receptor-mediated currents elicited by low concentrations of GABA. In general, anesthetics that inhibit NMDA receptors most, enhanced GABA(A) receptors least. This reciprocal relationship between anesthetic potency on GABA(A) versus NMDA receptors was also observed for the clinical anesthetics isoflurane, halothane, and cyclopropane. Studies using a range of GABA concentrations indicated that volatile aromatic anesthetics enhance GABA(A) receptor activity by shifting the open-close (gating) equilibrium towards the open channel state.

CONCLUSIONS

These findings suggest that GABA(A) receptors contribute variably to the behavioral actions of volatile anesthetics and imply that the molecular determinants of anesthetic action on NMDA and GABA(A) receptors are distinctly different.

Near-death experiences with reports of meeting deceased people

Few scientists have taken seriously the interpretation of near-death experiences (NDEs) as evidence for survival after death, even though most people having such an experience have become convinced that they will survive death and several features of NDEs are at least suggestive of survival. This article compares survival and some nonsurvival interpretations of NDEs in light of one feature suggestive of survival, that of reports of having seen deceased persons during the NDE. Several features of 74 NDEs involving such reports were compared with those of 200 NDEs not involving such reports. Although some of the findings could support either a survival or a nonsurvival interpretation, several other findings may weaken the primary nonsurvival hypothesis, that of expectation. Additionally, the convergence of several features suggesting survival and the convergence of features that require multiple kinds of alternative explanations, in individual cases as well as in large groups of cases, warrant our considering the survival hypothesis of NDEs more seriously than most scientists currently do.

Complications of elbow arthroscopy

BACKGROUND

Although the potential complications of elbow arthroscopy, including nerve injuries, have been described, the prevalence of their occurrence has not been well defined. The purpose of this paper is to describe the serious and minor complications in a large series of patients treated with elbow arthroscopy.

METHODS

A retrospective review of 473 consecutive elbow arthroscopies performed in 449 patients over an eighteen-year period was conducted. Of the 473 cases, 414 were followed for more than six weeks. The most common final diagnoses were osteoarthritis (150 cases), loose bodies (112), and rheumatoid or inflammatory arthritis (seventy-five). The arthroscopic procedures included synovectomy (184), debridement of joint surfaces or adhesions (180), excision of osteophytes (164), diagnostic arthroscopy (154), loose-body removal (144), and capsular procedures such as capsular release, capsulotomy, and capsulectomy (seventy-three).

RESULTS

A serious complication (a joint space infection) occurred after four (0.8%) of the arthroscopic procedures. Minor complications occurred after fifty (11%) of the arthroscopic procedures. These complications included prolonged drainage from or superficial infection at a portal site after thirty-three procedures, persistent minor contracture of 20 degrees or less after seven, and twelve transient nerve palsies (five ulnar palsies, four superficial radial palsies, one posterior interosseous palsy, one medial antebrachial cutaneous palsy, and one anterior interosseous palsy) in ten patients. The most significant risk factors for the development of a temporary nerve palsy were an underlying diagnosis of rheumatoid arthritis (p < 0.001) and a contracture (p < 0.05). There were no permanent neurovascular injuries, hematomas, or compartment syndromes in our series, and all of the minor complications, except for the minor contractures, resolved without sequelae.

CONCLUSIONS

Our results indicate that the prevalence of temporary or minor complications following elbow arthroscopy may be greater than previously reported. However, serious or permanent complications were uncommon.

Complications of repair of the distal biceps tendon with the modified two-incision technique

BACKGROUND

The purpose of this paper is to describe the complications that we encountered after using a muscle-splitting two-incision technique to repair avulsed distal biceps tendons.

METHODS

We conducted a retrospective review of the results of seventy-eight consecutive anatomical repairs of the distal biceps tendon performed through a muscle-splitting two-incision technique at our institution between 1981 and 1998. Four of the patients required a graft to restore length. The seventy-four tendons that were repaired primarily through the modified Boyd-Anderson approach were analyzed in detail and form the basis of this report.

RESULTS

Complications developed after twenty-three (31 percent) of the seventy-four repairs. The complications included five sensory nerve paresthesias (three lateral antebrachial cutaneous and two superficial radial nerve paresthesias) in five patients. A temporary palsy of the posterior interosseous nerve developed in one patient; it resolved in six months. Six patients complained of persistent anterior elbow pain. Heterotopic ossification that did not limit forearm rotation developed in four patients, a superficial wound infection developed in three, one tendon reruptured, three patients lost forearm rotation, and reflex sympathetic dystrophy developed in one patient. No radioulnar synostoses were observed in our series. Complications developed after ten (24 percent) of the forty-one acute repairs (performed fewer than ten days after the injury), six (38 percent) of the sixteen subacute repairs (performed ten to twenty-one days after the injury), and seven (41 percent) of the seventeen delayed repairs (performed more than twenty-one days after the injury). The surgeon's experience with this procedure had no apparent effect on complication rates.

CONCLUSIONS

Most of the morbidity from repair of the distal biceps tendon can be attributed primarily to a delay in the timing of the repair and secondarily to an extensive anterior exposure. More importantly, radioulnar synostosis is rare following the muscle-splitting modification of the two-incision technique, which can be performed safely even by surgeons with limited experience with this procedure.

Stress fractures of the pelvis in female navy recruits: an analysis of possible mechanisms of injury

The purpose of our study was to investigate possible risk factors and mechanisms for the development of pelvic stress fractures in female Navy recruits. We used a case-control retrospective study of female Navy recruits undergoing basic military training. We compared anthropometric and activity data between recruits with pelvic stress fractures (N = 25) and female recruits who completed training without injury (N = 61). Recruits developing pelvic stress fractures were significantly (p < 0.05) shorter and lighter and were more frequently Asian or Hispanic than recruits without stress fractures. In addition, recruits with pelvic stress fractures reported marching in the back of their training division, were road guards, and felt that their stride was too long during training activities more often than recruits without injury. Self-reported fitness, activities before recruit training, or a history of amenorrhea was not found to be associated with the development of a pelvic stress fracture in our population.

A team approach to the treatment of musculoskeletal injuries suffered by Navy recruits: a method to decrease attrition and improve quality of care

In 1991, musculoskeletal injuries prevented 488 recruits from completing basic training at the Naval Recruit Training Command, Great Lakes, Illinois. These losses cost the Navy an estimated $5 million. To respond to the large number of injured recruits, a multi-disciplinary team was developed in 1992. Along with this team, a three-tiered, systematic approach to injuries was implemented. These changes were associated with an increase in the recovery rate for injured recruits requiring physical therapy, a decrease in the amount of training time lost per injury, and fewer total lost training days due to musculoskeletal problems. In addition, this new system was associated with a decrease in the overall attrition rate for musculoskeletal injuries and a cost savings to the Navy of several million dollars per year.

Experience with portable ultrasound equipment and measurement of urine volumes: inter-user reliability and factors of patient position

A portable ultrasound unit has been developed that provides a noninvasive technique to measure urine volume. We assessed the effect of patient position on the accuracy of measurements as well as inter-user reliability and user training. There were 63 ultrasound measurements of urine volume made by a trained and an inexperienced examiner, and the values were compared to true volumes obtained by catheterization in 16 adults with a neurogenic bladder. Subjects were tested in the seated and supine positions. Correlation for ultrasound volumes between the trained and inexperienced examiners was highly significant. Accuracy and precision of the ultrasound measurements were not affected by patient position. Thus, little training is necessary to use this instrument, inter-user reliability is good, and accuracy and precision are clinically acceptable whether patients are in the seated or supine positions.

Effects of counselor's eye contact on student-clients' perceptions

This study investigated the effects of amount and direction of eye contact with the counselor on a student's perceptions. 48 undergraduate and graduate education majors were randomly assigned to one of six conditions in a 2 x 3 factorial design representing two levels of eye direction (eye-to-eye and eye-to-nose/mouth) and three amounts of eye contact (high = 85%, medium = 50%, low = 15%). Subjects had 10-min. standard interviews that differed only according to the six experimental conditions. Interviews were videotaped to assess maintenance of experimental conditons. Following the interview, subjects rated (5-high to 1-low) the interview on seven variables (comfort, attention, interest, ease, helpfulness, eye contact, and willingness to return). Interrater reliability for maintenance of experimental conditions was .87 on amount of eye contact and .03 for direction. Scheffé comparisons showed high and medium eye contact produced significantly higher ratings by student clients on attention, interest, eye contact, and willingness to return than low eye contact. There were no differences for direction of eye contact.